Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Friday, December 18, 2009

Hinny Shots and Anal Puckering

As some of you may know, there is a novel flu strain out there called H1N1, or, less accurately, Swine Flu. As others of you may also know, there is a vaccine available that is recommended for the following high risk groups:
  • Children/young adults between the ages of 6 months and 24 years
  • Household contacts of infants less than 6 months old
  • Pregnant women
  • Health care workers
  • People with health conditions (asthma; diabetes; etc.) putting them at high risk for flu complications
For those of you who have been hiding under a rock since Fall, the vaccine is being purchased and distributed by the government. This is as good an explanation as any as to why I have not been able to get ahold of any of the stuff.

Until now.

Finally, at long long last, I received an email from the state department of health notifying me that my order of 200 doses of H1N1 vaccine had been approved. Unfortunately, they were unable to provide me with a shipping date. They also sent me another mass email informing me that as of 12/11/09, they would be suspending all shipments (ostensibly, "for the holiday") and would resume 1/4/10.

Shit.

Then two days ago, I received a box from UPS. Inside, I found a plastic box. It was a sharps receptacle, a container specifically designed for safe disposal of hypodermic needles. I examined the package at length; the only other thing in the box was a sheet of paper naming the company that had sent the thing. The name rang a bell; sure enough, it was the company distributing H1N1 for the state. Given that the government was not only going to be providing the shots but also all the equipment and supplies for its administration, this was a very good sign indeed.

The next day brought another good sign: another delivery consisting of one box containing two plastic pouches, each containing one hundred syringes with attached needles, alcohol wipes, and little cards upon which flu shot administration could be documented and given to patients. This was an excellent sign!

Then earlier today, UPS came again. This time, the cardboard shipping box contained another box made of styrofoam. Hidden within, nestled among half a dozen cold packs, sat two shrink-wrapped packages of ten little cartons containing vials with 10 doses each of H1N1 vaccine. I'm in business!

(Eventually, I got back to check my email, and discovered that I had to print out and complete reporting forms for each dose given, and then send them back to the health department "in a timely fashion." I knew it couldn't be that easy.)

I was just finishing up with a patient as the vaccine was being delivered. Realizing what the package was likely to contain, and aware that the patient was undergoing cancer chemotherapy (a definite indication for H1N1 vaccination), I grabbed her before she could leave so I could get her immunized.

I tore open one of the government-supplied packages of syringes, and freed it from its paper overwrap. It was an unfamiliar design, but I figured that the basic idea is pretty universal. I drew up the first dose, half a milliliter of the treasured serum, and approached the patient's bare left upper arm.

I need to interject at this point that I'm damn good at giving shots. What I do is say, "Count to three" AS I'M GIVING THE SHOT. By the time they start to count, it's already done. I've given out about 300 seasonal flu shots this year so far, and the most common response to my injection technique is, "Was that it?" Even though I hadn't ever used this particular model of syringe/needle combo, I saw no need to alter my technique.

I swiped the site with alcohol and inserted the needle as I began to say, "Count to three." I depressed the plunger and watched as the vaccine disappeared into the tissue where it belonged. Suddenly, there was a loud SNAP as I finished the injection, and to my horror, there was no needle at the end of the syringe!

It is the essence of professionalism that the expression on my face never changed as the words, "Oh my fucking god, where did the needle go? Oh my fucking god, did I break the needle off in her arm??!? Oh my fucking god please no no no no no where did that fucking needle go???!?" raced through my mind, and my lab coat sucked all the way up to my splenic flexure.

I peered carefully at the patient's arm. Nothing out of the ordinary. But how could I tell if there was a needle broken off all the way under the skin? I poked at it gently.

"Does that hurt?" I asked the patient.

"A little," she answered.

I've had tiny glass shards stuck in my foot and they hurt like a mofo with the slightest pressure, so I thought it was unlikely that a broken-off needle would hurt just "a little."

Next I examined the syringe in my hand. I noticed that there was a stretched out spring within the barrel that I didn't remember seeing there earlier. Eventually, after a great deal of quizzical staring, I finally made out the needle and its clear plastic hub nestled safely within the syringe's hollow plunger. Clearly a brilliant design from the point of needle safety. On the other hand, it was downright hazardous to my cardiac health. The time it took to convince myself that I hadn't left an inch-long metal sliver in my patient's arm was marked by asystole and an adrenaline burst the likes of which I hadn't experienced in decades.

Finally, I began breathing again. First, I exhaled. Then I broke out in a sweat. Eventually I calmed down enough to get on with my day. I used the new syringes to give out several more shots, and even though I now knew what to expect, that SNAP still got me every time. I can only hope that I get used to it.

In the meantime, though: Hey everyone, I have H1N1! Come and get it.

18 Comments:

At Sun Dec 20, 03:22:00 AM, Blogger Dr. K said...

You should warn your patients that the H1N1 jab hurts like a mofo (to use your term) for 2-7 days after receiving their jab. This is not like the seasonal flu jab ... this one *hurts* for days afterward.

 
At Sun Dec 20, 06:21:00 AM, Blogger XE said...

This post made my morning, thank you!

 
At Sun Dec 20, 08:46:00 AM, Blogger Jay said...

One question Dino:

If a patient is immunosuppressed due to chemotherapy, how do they mount an immune response to the vaccine?

 
At Sun Dec 20, 09:04:00 AM, Blogger OHN said...

I am sorry to tell you that the image of your lab coat sucking up to your splenic flexure made me laugh right out loud this morning.

I needed that :)

I can't remember what injection I got, but they used a syringe exactly like you described. The snap sound freaked me out too.

 
At Sun Dec 20, 10:05:00 AM, Blogger rlbates said...

So happy it ended well

 
At Sun Dec 20, 10:46:00 AM, Blogger Shelby said...

that's hilarious. for some reason, I can see Dr Fleishman (sp?) acting out that scene in a episode of northern exposure.. then marilyn (his assistant who he didn't think was his assistant.. maybe she wasn't) would come in and show him where the needle actually was.. then he'd say 'oh' and then go outside and puke.

funny. funnier tho because it really happened and you told us about it.

so enjoyed visiting here this morning.

cheers :)

 
At Sun Dec 20, 09:59:00 PM, Blogger ananas said...

Ditto what Dr.K said - that thing HURTS afterward. And maybe warn your patients about the snapping sound, it scared the daylights out of me when I got my shot.

 
At Mon Dec 21, 10:48:00 PM, Blogger Geoff said...

That's commendably hi-tech. While the Australian government has thoughtfully supplied H1N1 jabs for all who want them, they also supplied the cheapest, lousiest Chinese syringes and needles I have ever seen. Adequate... but only just. No fear of needles retracting here.

Odd about the sore arms described by your correspondents, mine didn't hurt and I have had no complaints from the thousands I've given in the last two months.

 
At Mon Dec 21, 11:08:00 PM, Blogger StorytellERdoc said...

Glad that you got your supply! I'm also glad that our Er doesn't provide those for the public! I could only imagine the waiting room then!

Have a good day.

 
At Tue Dec 22, 03:44:00 PM, Anonymous Flo said...

I think I've used those before, you are not supposed to fully depress the plunger until after you've given the shot and removed the needle, then you press all the way and the needle retracts. I'm always scared that I'll depress it too much while giving the shot.
~Flo

 
At Tue Dec 22, 06:11:00 PM, Blogger TOTWTYTR said...

Dr. K, my seasonal flu shot hurt a lot more than my H1N1 shot. OTOH, my mother is still sore almost two weeks later. I'm guessing that there is a wide range of responses.

Dino Doc, those syringes are nice, but they do take a bit of getting used to. I "wasted" one just to get used to how they work. I still pull the needle out before I snap it closed, just in case.

 
At Tue Dec 22, 08:24:00 PM, Blogger #1 Dinosaur said...

Dr. K et al: It seems to me that pain after the injection is not inherent to any particular formulation (H1N1 vs. seasonal flu vs. anything else). Whether it's a function of depth of injection (true IM vs inadvertent SQ in fat people; not even sure which would hurt more) or just random proximity to vessels/nerves/etc.; no clue. I've definitely had responses all over the map. FWIW, neither my H1N1 nor seasonal jab hurt at all.

 
At Tue Dec 22, 09:11:00 PM, Blogger Homebody said...

I nearly ruined my laptop over this post.

And Kudos to you for keeping your cool, especially with that particular patient. Last thing she needed was more to deal with, even if it was ultimately nothing. It really shows how much you care about your patients, even when you are making fun of yourself.

 
At Wed Dec 23, 05:25:00 PM, Blogger NikkiK said...

came over her from Cranky Lit Professor, (http://crankylitprof.wordpress.com/) and that was so hilarious I'll keep coming back. Thanks! And have a great day!

 
At Sat Dec 26, 10:19:00 PM, Blogger Valerie said...

Ohmigosh!

How on earth could they distribute this new tech without at least ALERTING you to the way it works?

Read this allowed to my beloved the familymedicineguy. At first he wondered whether you didn't realize you'd been issued the nasal version. Then he realized what you were dealing with and said "oh, hate those, won't use them."

 
At Sun Dec 27, 02:44:00 AM, Anonymous Anonymous said...

You probably got the VanishPoint prefilled syringes. I love them. In fact, I use them for all the vaccines I administer (except those that come in prefilled syringes that require only a needle) & I have changed to using them to dispense methotrexate, cyanocobalamin, etc. Patients love them!

Flo - you inject & depress completely. The spring mechanism allows controlled & complete withdrawal. If you wait to depress completely after withdrawing from the pt you could 1) not administer the full dose & 2) spray fluid, either vaccine or bodily fluid to surrounding areas/people.

 
At Sat Jan 02, 12:55:00 PM, Blogger Dragonfly said...

I've heard stories about the H1N1 vax being different everywhere. I had mine in Australia and zip in terms of pain (though they were concerned about latex allergies, because that is what they reckon the 1-2 serious reactions in Australia were due to). Relatives who live in Europe were told that the Australian one is better (???) than the one available in some of the countries over there...

 
At Thu Jan 21, 07:49:00 PM, Anonymous the Muse, RN said...

LMAO!!! (with you, not at you) Did the same exact thing WITH THE SAME HORRIFIED verbiage yelling at me in my head after giving an injection to a newborn with one of those nifty new things. omg.

Though I was reassured almost immediately (not nearly soon enough) that my worst fears had not just been realized, it was hours before my breathing returned to normal.

Thanks for the visual of someone else's highly organized and appropriate orientation (sic) to new healthcare technology.

 

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